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Original Article
345
Complications of Cement-Augmented Dynamic Hip Screws in
Unstable Type Intertrochanteric Fractures A Case Series Study
Meng-Huang Wu, MD; Po-Cheng Lee1, MD; Kuo-Ti Peng, MD, PhD; Chi-Chuan Wu1,
MD; Tsung-Jen Huang, MD; Robert Wen-Wei Hsu, MD
Background: Polymethylmethacrylate (PMMA) cement-augmented dynamic hip screws
(DHS) have been used as a solution in unstable intertrochanteric fractures
(ITF). Our aim was to investigate the complications in PMMA cement-augmented DHS.
Methods:
All patients who had received DHS plate osteosynthesis with or without
PMMA cement augmentation from August 2005 to July 2009 in one medical
center were retrospectively reviewed. The fractures were classified as unstable (31-A2.2, 31-A2.3 and 31-A3) on the basis of the Arbeitsgemeinschaft
für Osteosynthesefragen classification. Inclusion criteria were patients older
than 75 years, unstable ITF treated with cement-augmented DHS, and a minimum of 12 months of follow-up. Exclusion criteria were stable ITFs, incomplete chart records and imaging studies, loss to follow-up or death before
bone union.
Results:
Three hundred twenty-one patients received DHS during the study period.
Sixty-seven patients were included in the study (25 men and 42 women;
mean age, 81.2 years). The mean follow-up time was 40.2 months, and the
mean union time was 18.5 weeks (12-40 weeks). No patient had a lag screw
cut-out. Six patients had delayed union or nonunion with side plate failures,
including side plate breakage in 1 patient, screw breakage in 3, screw pullout
in 1, and recurrent side plate breakage and screw breakage in 1. Deep infection occurred in 1 patient, and 1 had osteonecrosis at the femoral head. The
procedure-related complication rate was 8.9%.
Conclusions: Cement-augmented DHS have a different failure mode than screw cutout in
conventional DHS. Failures tended to be more related to delayed union,
nonunion and resultant side plate construct failure.
(Chang Gung Med J 2012;35:345-53)
Key words: bone cement, complication, dynamic hip screw, intertrochanteric fracture, polymethylmethacrylate
From the Department of Orthopedic Surgery, Chang Gung Memorial Hospital at Chiayi; 1Department of Orthopedic Surgery, Chang
Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, Taoyuan, Taiwan.
Received: Nov. 30, 2010; Accepted: Jan. 30, 2012
Correspondence to: Dr. Po-Cheng Lee, Department of Orthopedic Surgery, Chang Gung Memorial Hospital at Linkou. 5, Fusing
St., Gueishan Township, Taoyuan County 333, Taiwan (R.O.C.) Tel: 886-3-3281200 ext. 2423; Fax: 886-3-3289582;
E-mail: [email protected]; [email protected]
Meng-Huang Wu, et al
Complications of cement-augmented DHS
O
steoporotic intertrochanteric fracture (ITF) is the
second leading cause of hospitalization of elderly patients.(1) Successful treatment is challenging, as
many factors are related to the patient’s final prognosis. Stable fracture fixation is the goal of treatment to
improve the quality of life and decrease morbidity in
patients with hip fractures, but this in turn depends
on the type of fracture and bone quality.(1) In stable
ITFs, osteosynthesis using dynamic hip screws
(DHS) provides good results, but for unstable ITFs,
the best treatment method is still a matter of controversy. Poor bone quality is responsible for common
complications, such as failure of fixation, varus collapse and lag screw cut-out, in elderly patients. (2)
Kim et al. found that the complication rate when
using conventional DHS in unstable ITFs can be as
high as 50% because of screw cut-out.(3) Several
methods, such as the Medoff sliding plate,
intramedullary nailing, primary endoprosthesis, and
bone augmentation using polymethylmethacrylate
(PMMA) cement or calcium phosphate cement, have
been proposed for unstable ITFs. (4-8) Since 1975,
PMMA cement-augmented DHS have been used as a
solution in unstable ITFs by adding an anchoring
ability to the lag screw.(9) Some encouraging results
have been observed, showing a higher success rate
and better functional recovery than with conventional DHS. (10,11) However, complications such as
osteonecrosis of the femoral head, nonunion, infection, and screw cut-out can still occur when using
PMMA cement augmentation.(7,12) Therefore, our aim
was to investigate the complications and failure
modes in PMMA cement-augmented DHS. This retrospective study was approved by the institutional
review board of our hospital (No 99-1002B).
METHODS
Subjects
All patients who had received DHS plate
osteosynthesis with or without PMMA cement augmentation from August 2005 to July 2009 in one
medical center were reviewed. The fractures were
classified as stable (31-A1 and 31-A2.1) or unstable
(31-A2.2, 31-A2.3 and 31-A3) on the basis of the
Arbeitsgemeinschaft für Osteosynthesefragen/
Orthopaedic Trauma Association classification.(13)
The surgeries were performed in the traumatic orthopedic department by 3 trauma orthopedic surgeons.
346
Inclusion criteria were patients older than 75 years,
unstable ITF treated with cement-augmented DHS,
and a minimum of 12 months of follow-up.
Exclusion criteria were stable ITFs, incomplete chart
records and imaging studies, loss to follow-up or
death before bone union. A retrospective chart
review was performed to collect preoperative, postoperative and intraoperative data, including local and
systemic complications. Serial radiographs from the
preoperative period and the postoperative period
until fracture union was achieved were reviewed.
Surgical techniques
All surgical operations were performed by 3
senior surgeons with extensive experience in the use
of DHS and cement augmentation techniques. The
indications for cement-augmented DHS were unstable ITFs, including those with a large posteromedial
(PM) fragment, a multifragmentary status, a reverse
oblique pattern, and a transtrochanteric pattern in
elderly patients with poor lag screw purchase in the
femoral head bone. The DHS was inserted using a
standard surgical procedure under C-arm fluoroscopic control. The reduction was considered acceptable
when the following criteria were met: anatomic or
slight valgus alignment on the anteroposterior view,
alignment with parallel or slight cervical anteversion
on the lateral view, and no more than 1 cm of displacement between the 2 major fracture fragments.
The reduction was maintained by traction and rotation of the injured leg with a boot. The guide wire
was inserted in the femoral neck and aimed beneath
the center of the femoral head, without penetration
into the hip joint. A 135-degree side plate, with at
least four holes available below the fracture, was
used. Before the side plate was secured to the lateral
aspect of the femur, the traction was released to
ensure cortical contact between fragments when fracture distraction occurred. Low-viscosity PMMA
(Surgical Simplex P, Stryker-Howmedica, Limerick,
Ireland) was injected into the screw tract of the proximal fragment when the patient’s systemic blood
pressure was more than 120 mmHg. A dual-speed
injection gun (Stryker, Portage, MI, U.S.A.) was
used to deliver the cement. The amount of cement
retained in the patients was recorded. Because of the
nature of proximal femur anteversion, the cement in
the proximal fragment had a tendency to flow backward and leak into the fracture gap when the patient
Chang Gung Med J Vol. 35 No. 4
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Meng-Huang Wu, et al
Complications of cement-augmented DHS
was lying in the supine position. To overcome the
proximal femur anteversion, the fracture table was
tilted 30 degrees toward the contralateral side of the
injured limb in patients receiving cement augmentation. For maximum cement infiltration, the injection
gun was operated in the pressure mode, and a plastic
femoral nozzle with an appropriate size of 12 mm in
diameter was inserted as far as possible into the
femoral head. The application of a femoral nozzle
with a diameter similar to the screw tract has the
advantage of completely obliterating the screw tract
during cement injection. This can enhance cement
intrusion into the surrounding cancellous bone interstices and prevent cement leaking from the screw
tract into the fracture site. Cement injection was
started from the most proximal part of the screw tract
while simultaneously pulling the femoral nozzle
backward; the cement injection was stopped when
the cement intrusion reached within 1 cm of the cervicotrochanteric area. The femoral nozzle was then
removed, and the assembled hip screw and plate
were inserted immediately. Our cement augmentation technique also blocked the screw from sliding
within the barrel of the plate because the cement surrounded both the threads and the shaft of the screw.
This was intended to prevent the excessive screw
sliding commonly encountered in unstable fractures.
The filling pattern in our patients showed a diffuse
distribution of the cement in the proximal fragment
(Fig. 1).
RESULTS
Three hundred twenty-one patients received
DHS plate osteosynthesis with or without PMMA
cement augmentation during the study period.
Seventy-seven patients received PMMA cement-augmented DHS for closed unstable ITFs. Six patients
died (4 men and 2 women, Table 1) and 4 patients
were lost to follow-up before bone union. Of the
remaining 67 patients, 25 were men and 42 were
women, and the mean age was 81.2 years (range, 7594 years). Thirty-eight fractures involved the left
side and 29 involved the right. Sixty-three fractures
resulted from falls, 2 from high-energy mechanisms
(motor-vehicle accidents), and 2 were revision surgeries after conventional DHS. According to the
American Society of Anesthesiologists physical status classification (www.asahq.org/clinical/physical-
Chang Gung Med J Vol. 35 No. 4
July-August 2012
Fig. 1 Diffuse cement distribution pattern in cement augmented dynamic hip screw surgery.
status.htm), 2 were class I, 32 were class II, 29 were
class III, and 4 were class IV. Four patients were
completely non-ambulatory preoperatively. The average length of hospitalization was 9.47 days (range, 422 days). The mean operation time was 71.2 minutes
(range, 62-93 minutes). The mean fluoroscopy time
was 82.3 seconds (range, 60-130 seconds). The mean
operative blood loss was 260 mL (range, 80-450
mL). All patients had an acceptable reduction of the
fracture and a desired position for the lag screw.
Postoperatively, the mean follow-up time was 40.2
months (range, 12-56 months). Except for 1 patient
requiring a total hip replacement because of deep
infection, and 6 patients who had revision surgeries,
the mean union time for the remaining 60 patients
was 18.5 weeks (12-40 weeks). Eventual fracture
union was achieved in 66 patients by 52 weeks.
Eight patients had complications (Table 2); none
had a lag screw cut-out. Six patients had implant failure that required further intervention to achieve fracture union. The most common failure mode was
delayed union or nonunion with side plate failure,
which included side plate breakage in 1 patient (Fig.
Meng-Huang Wu, et al
Complications of cement-augmented DHS
348
Table 1. Mortalities and Morbidities
Age
Time interval
Events
Final status
87
Sex
F
Co-morbidities
HTN, Peptic ulcer disease
ASA
3
2 months
Ileus, hyponatremia
Discharged
84
F
DM, HTN, CVA
3
3 months
Neurogenic bladder, angina
Discharged
75
F
DM, HTN, Adrenal insufficiency
2
10 months
L1 compression fracture
Vertebroplasty and
discharged
85
F
Nil
3
3 days
UGI bleeding
Discharged
79
F
Bedridden, liver cirrhosis
3
14 months
Pneumonia
Expired
85
M
HTN, HCV
2
5 days
Acute cardiac arrest
Expired
88
M
Multiple myeloma, bilateral
inguinal hernia status post
3
6 months
Incarcerated hernia with sepsis
Expired
79
M
HTN, CHF, COPD, old TB
3
13 months
TB pneumonia
Expired
78
F
ESRD
3
5 months
Peritonitis
Expired
75
M
HCC with multiple *meta
3
16 days
Septic hip
Expired
Abbreviations: HTN: hypertension; DM: diabetes mellitus; HCV: hepatitis C virus carrier; CVA: cerebrovascular accident; COPD:
chronic obstructive pulmonary disease; CHF: congestive heart failure; TB: tuberculosis; ESRD: end-stage renal disease; HCC: hepatocellular carcinoma; UGI: upper gastrointestinal tract; *: 77 patients received cement augmented dynamic hip screws.
Table 2. Complications of Cement Augmented Dynamic Hip Screws*
Age Sex
Diagnosis
Co-morbidities
68
F
Left ITF
DM, HTN
75
F
Left ITF
DM, HTN, HBV,
adrenal insufficiency
78
F
Left ITF s/p DHS
HTN, COPD
68
F
Left ITF
HTN
47
M
Left ITF
Smoking
87
F
Left ITF
56
M
66
M
Time to failure (m) Complications
Operation
Time to union (m)
5
Screw breakage
Side plate exchange
and bone graft
6
22
Screw breakage
Side plate exchange
8
5
Screw breakage
Side plate exchange
7
Side plate breakage
Side plate exchange
and bone graft
6
3
Recurrent plate
breakage
Side plate exchange
and bone graft
6
CRI, HTN, psoriasis
3
Plate pullout
Side plate exchange
and bone graft
5
Right ITF
HTN, CVA
3
Osteonecrosis
–
–
Right ITF
Gout, asthma, HTN
6
Infection
Debridement and 2
stage THR
–
12
Abbreviations: ITF: intertrochanteric fracture, s/p: status post; DHS: dynamic hip screw; DM: diabetes mellitus; HTN: hypertension;
HBV: hepatitis B virus carrier; COPD: chronic obstructive pulmonary disease; CRI: chronic renal insufficiency; CVA: cerebrovascular accident; THR: total hip replacement; *: 67 patients included in this study.
2), screw breakage in 3 patients (Fig. 3), screw pullout in 1 patient (Fig. 4), and recurrent side plate
breakage and screw breakage in 1 patient. All these
patients had a good post-op ambulatory status and all
denied any traumatic event before implant failure.
They all had side plate revision and 4 patients had
allogenic bone grafting in the bone gap. Final bone
unions were achieved in all patients. Deep infection
occurred in 1 patient, who required surgical debridement and a total hip replacement. One patient had
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Meng-Huang Wu, et al
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Fig. 4 Side plate screw pullout.
Fig. 2 Side plate breakage from the screw hole.
osteonecrosis at the femoral head without clinical
symptoms. Four patients had co-morbidities during
hospitalization, but all were discharged after treatment (Table 2). Six patients died of causes such as
pneumonia, septic hip, acute cardiac arrest, incarcerated hernia, and peritonitis, but none of these causes
of death were directly related to cement use. The
procedure-related complication rate was 8.9%.
DISCUSSION
Fig. 3 Side plate screw breakage.
Chang Gung Med J Vol. 35 No. 4
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Conventional DHS for stable type ITFs have
demonstrated good results; however, the complication rate of conventional DHS can be as high as 50%
in patients with osteoporosis and unstable fractures.(3)
Screw cut-out is the most common complication;
Bonnaire et al. found that screw cut-outs were
strongly connected to the bone density of the trabecular bone in the femoral head in conventional
DHS.(14) In our series, poor trabecular bone quality in
the femoral head did not lead to screw cut-out if
cement augmentation was adequate to strengthen the
osteoporotic bone. Failures were more related to
delayed union or nonunion with side plate failure,
including side plate screw pullout, screw breakage,
and plate breakage, which are rarely reported.(15-17)
Meng-Huang Wu, et al
Complications of cement-augmented DHS
Because of the high complication rate, the use
of DHS in unstable ITFs has become less favored.
The use of intramedullary devices provides more
effective control over screw sliding by acting as a
lateral buttress, resulting in a tendency to less frequent cut-out. (16) On the other hand, iatrogenic
femoral fractures are a persistent risk when using
intramedullary devices.(18) Anglen et al. observed a
dramatic increase from 3% to 67% in the use of
intramedullary devices in ITF in recent decades.(19)
With more frequent use and technique-related errors,
patients managed with intramedullary nailing have
had more procedure-related complications, particularly bone fracture.(19) Recent reports have shown no
significant differences in the final functional outcome between DHS and intramedullary devices.(20,21)
Furthermore, intramedullary devices for unstable
ITFs have the disadvantages of difficult reduction,
intraoperative complications as a result of the bulky
proximal part, persistent thigh pain due to stress concentration around the nail tip, implant failure due to
varus angulation, and risk of femoral shaft fracture.(1,18)
PMMA cement augmentation for DHS is an
effective way to prevent screw cut-out in osteoporotic ITF treatment.(10) Diffuse distribution of low viscosity cement has provided better load to cut-out in
several reports. (10,22,23) Choueka et al. performed a
cadaver study and found the greatest average load to
failure was increased in the cemented sliding hip
screw (4.0 x 103 N), and the lowest was in the uncemented sliding hip screw (3.6 x 103 N).(23) Another
cadaver study by Augat et al. found significantly better initial stability with the cement-augmented sliding hip screws in unstable ITFs.(22) Clinical reports
show encouraging results for cement augmentation.
In a report of 53 unstable ITFs from Bartucci et al., 1
failure (in 21 fractures) in the cement-augmented
group and 10 failures (in 17 fractures) in the noncement-augmented group were due to failure of fixation (p < 0.01).(14) In a prospective comparison study
of conventional DHS and cement-augmented DHS in
unstable ITFs by Lee et al., screw sliding, femoral
shortening, and varus collapse of the proximal fragment were all significantly reduced in the cementaugmented group at the 1-year follow-up (p < 0.001,
p < 0.001, p < 0.001, respectively), and the mean hip
pain score was significantly lower in the cement-augmented DHS group (p < 0.008).(11)
350
In our series, the procedure-related complication
rate was 8.9%, without screw cut-out from the
femoral head. This was because of better fixation of
the lag screw inside the femoral head and blockage
of barrel sliding by the cement to maintain fracture
reduction and prevent screw cut-out and malunion in
conventional DHS.(24) This construct is similar to a
fixed-angle device and therefore can be used in
unstable fractures, decreasing the rate of femoral
shortening-related complications of conventional
DHS. (11) However, complications were still noted
with this method. Cheng et al. reported that 6 of 38
patients with cement-augmented sliding hip screws
had late complications such non-union at the
trochanteric fracture, protruding pin, partial destruction of the femoral head, subcapital fracture of the
femoral neck, and avascular necrosis of the femoral
head 1 year after surgery. These were related to inappropriate placement and an excessive amount of
cement, together with inadequate new bone formation.(12) Side plate failure is very rare with conventional sliding hip screws, and only 4 cases, which
were related to femoral shortening and varus
malalignment, have been reported. (17,25) A similar
metal failure was also reported with intramedullary
nails when there was a short nail length in the
gamma nail, loss of PM support or overdistraction
without bone-to-bone contact, and varus angulation
during fixation. (26) Similar factors may produce a
varus deforming force, causing implant failure from
the side plate screw hole, screw-plate junction with
screw breakage, or screw-bone interface with screw
pullout when the side plate has an inadequate length
and fixation.(16)
The construct of cement-augmented DHS is different from that of conventional DHS because the
fixed lag screw without a telescoping effect will have
a greater load transfer from the implant. Apel et al.
found that the PM fragment is the keystone to
decrease varus moment and provide stability in
ITFs.(27) In the presence of a large PM fragment in
unstable ITFs, anatomic reduction and fixation of the
PM fragment allowed the femur to resist an average
maximum load which was 57% greater than identical
fractures with the fragment excluded. Fixation of a
small PM fragment increased construct strength by
an average of 17% over no fixation.(27) In unstable
ITFs, the PM fragment may be too comminuted to be
fixed and additional bone grafting with iliac bone,
Chang Gung Med J Vol. 35 No. 4
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Meng-Huang Wu, et al
Complications of cement-augmented DHS
allogenic bone, or a bone substitute should be strongly considered to provide PM support and prevent
construct failure. Besides lack of PM support, the
length of the side plate may have been another reason for the implant failures in our series. Verhofstad
et al suggested that a 2-hole side plate is sufficient in
stable ITFs. (28) However, in patients with severe
osteoporosis with unstable ITFs, side plate pullout
still can be observed, even in low energy trauma with
a standard side plate with 4 screw holes. (15) Side
plates with 4 screw holes were used in 3 patients
with screw breakage, and a side plate with 5 screw
holes was used in another case. Facing greater putout
force than with stable fractures, a longer side plate
(more than 4 screw holes) may be required to ensure
the amount of effectively-purchased cortex, provide
a more divided stress distribution to the longer plate
on more screws and provide a longer lever arm to
resist the varus moment. Unlike screw pullout and
screw breakage, side plate breakage from the junction of the lag screw is related to a lack of PM support, but not inadequate side plate fixation. The revision surgery should include side plate exchange and
PM bone grafting. If PM support cannot be ensured,
a Dimond-Hughston medial displacement osteotomy
is recommended to correct alignment and provide
PM stability.(29) Protective weight-bearing should be
used until a bone healing sign is noted on radiography, because implant failure occurred as late as 12
months after surgery with minor trauma in our series.
Cheng et al. also reported that most patients had late
complications because of impaired healing ability in
osteoporotic bone.(12,30)
One case of avascular necrosis of the femoral
head was noted but the patient had no clinical symptoms. Concerns about thermal necrosis when using
PMMA cement have been proposed in several studies. Heini et al. injected approximately 36 ml of bone
cement into the femoral head and femoral neck with
a resultant mean temperature increase of 22.1°C at
the femoral neck.(31) A temperature rise of this magnitude is cause for concern with regard to thermal damage to blood vessels and femoral head necrosis.
Stoffel et al. found the mean increase in temperature
at the femoral neck was 3.7°C in augmented bones,
using a modified method.(7) Boner et al. found the
highest temperatures were measured inside the
PMMA, with a significant drop in average maximum
temperatures from the center of the PMMA to the
Chang Gung Med J Vol. 35 No. 4
July-August 2012
PMMA/bone interface.(32) There is a risk of thermal
necrosis with PMMA layer thicknesses greater than
5.0 mm. No risk of thermal necrosis at the
PMMA/bone interface or in the surrounding bone
was found when using up to 6.0 cc of PMMA.
Clinical reports of PMMA cement augmentation
showed a low incidence of osteonecrosis; Cheng et
al. reported only 1 case of osteonecrosis among 38
patients that received a Dimon-Hughston displacement osteotomy and cement augmentation. (12)
Therefore, the risk of osteonecrosis seems to be low
when using PMMA cement augmentation in this
modified technique.
Limitations
This retrospective study cannot provide detailed
information and some patients may have been lost to
follow-up. The follow-up rate was 87% and all had
complete records which provided most of the information needed to reduce these limitations. To date,
no biomechanical study has been able to determine
the adequate length of the side plate in cement-augmented DHS. However, this series can provide information to prevent complications when using this
technique in patients with severe osteoporosis.
Conclusions
Cement-augmented DHS have a different failure
mode from screw cutout in conventional DHS. The
failed cases were more related to delayed union,
nonunion and resultant side plate construct failure.
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July-August 2012
353
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९ּրЕࡁտ
ӓ‫؜‬। Ղߦј1 ೆ઼ղ ӓૄᅞ1 เᓐ̥ ధ͛ቶ
ࡦ ഀĈ ֹϡ੻ͪ‫ڪ‬જၗ។ొ੻੪Ξͽ‫ڼ‬ᒚ̙ᘦ‫̝ؠ‬ᖼ̄ม੻ԶĂҭᓜԖ˯̪ѣΞਕ൴Ϡ‫׀‬
൴াĄώࡁտϫ۞ߏԓ୕˞ྋ੻ͪ‫ڪ‬જၗ។ొ੻੪̝‫׀‬൴াĄ
͞ ‫ڱ‬Ĉ а໖̶‫ژ‬д 2005 ˣ͡Ҍ 2009 ˛͡ม‫ٺ‬ಏ˘ᗁጯ͕̚̚ତ‫צ‬જၗ។ొ੻੪‫ڼ‬ᒚᖼ̄
ม੻Զ̝ঽˠĄќ९୧ІΒ߁ Arbeitsgemeinschaft für Osteosynthesefragen classification ̶ᙷ̚۞̙ᘦ‫੻ؠ‬Զ (31-A2.2, 31-A2.3, 31-A3) ֹϡ੻ͪ‫ڪ‬જၗ។ొ੻੪Ăѐࡔ
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ညĂ‫੻ٺ‬ᕽЪ݈εΝ੠ᖸٕѪ˸Ą
ඕ ‫ڍ‬Ĉ ѣ 321 ࣎ঽˠତ‫צ‬જၗ។ొ੻੪͘ఙĂ‫ ̚׎‬67 ࣎ତ‫ڪͪ੻צ‬જၗ។ొ੻੪Ğ25 շĂ
42 ̃ğĂπӮѐ᛬ 81.2 ໐Ą੠ᖸॡมπӮ 40.2 ͡ĄπӮᕽЪॡม 18.5 ‫׹‬Ğ12 Ҍ 40
‫׹‬ğĄ՟ѣঽˠѣ੻੪ࡍ΍Ă6 ࣎ঽˠѣ‫ؼ‬ᏵᕽЪٕϏᕽЪ͔੓઎᐀‫ڕ‬εୀΒ߁ 1 ࣎
઎᐀‫ڕ‬ᕝෘĂ 3 ࣎੻੪ᕝෘĂ 1 ࣎੻੪ᗫ௲Ă̈́ 1 ࣎ͅᖬ઎᐀‫ڕ‬ᕝෘĄஎొຏߖ 1
ҜĂ৿ҕّ۵੻ᐝᗼѪѣ 1 ЩঽˠĄ
ඕ ኢĈ ੻ͪ‫ڪ‬જၗ។ొ੻੪д‫ڼ‬ᒚ̙ᘦ‫ؠ‬ᖼ̄ม੻Զ‫׍‬ѣ‫็׶‬௚જၗ។ొ੻੪ࡍ౅̙Тԛ
ё۞‫׀‬൴াĄ‫׀׎‬൴া̂кྫྷ‫ؼ‬ᏵᕽЪٕϏᕽЪ͔੓઎᐀‫ڕ‬εୀѣᙯĄ
(‫طܜ‬ᗁᄫ 2012;35:345-53)
ᙯᔣෟĈ੻ͪ‫ڪ‬Ă‫׀‬൴াĂજၗ។ొ੻੪Ăᖼ̄ม੻ԶĂpolymethylmethacrylate
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